How Well Do You Know Your Patient?

Can you describe a day in your patient’s life? As treating chronic pain with opioids comes under greater and greater scrutiny, one of the lessons that has become more evident to prescribers is that initial assessment and follow-up are no longer a matter of just gathering facts about the characteristics of the pain and its level. We cannot provide safe and effective care unless we understand the patient’s context.

This subject was addressed in a recent book that we highly recommend. In Listening for What Matters: Avoiding Contextual Errors in Health Care, authors Saul Weiner and Alan Schwartz write that contextually appropriate care requires obtaining a wider breadth of information about many aspects of the patient’s life, including his or her financial situation, social support, competing responsibilities, and cognitive abilities.1

It also means paying attention to information offered by the patient and probing further, an approach that can result in making better treatment decisions. For example, if the patient hasn’t followed through with physical therapy (PT) appointments or making an appointment with a consultant, before immediately concluding that the patient is “noncompliant,” do you ask why? It may be that her husband has fallen ill and she is now the full-time caregiver. Or perhaps a friend who has been driving the patient to appointments can no longer do so, and the patient can’t afford a taxi. Perhaps you can make some recommendations to deal with these problems.

It is also very relevant to ask about the patient’s support system. Does she have a family? Children at home? And does the patient have any activities that he enjoys doing? And, on the flip side, stress, anxiety, and depression are well known to exacerbate pain, and treating them can be an important component of improving pain and function. You won’t know about this if you don’t ask!

In a study involving “mystery patients” wearing recorders, Weiner and Schwartz found that physicians planned appropriate care in 73% of the visits when the case did not include a complicating medical or contextual factor, 38% when the complication was only medical, and only 22% of the time when the case included both complicating contextual and medical factors.2 That is, in medically complicated cases when the physician fails to consider contributing factors in the patient’s life, only a 1/5 of the patients received appropriate care!

When it comes to patients who have chronic pain, it is at least as important to learn about the patient’s functioning as about his pain level. A good starting point is, “What is a day in your life like?” If the patient says, “I’m better—I can now walk my dog again,” ask for details: “How far? How many minutes? What size dog do you have? How many hours a day are you now spending in bed?” You need to gather enough information to create a picture of the patient’s daily life, not just that his function has improved to a 5 out of 10 or by 30%. Numbers and percentages tell you very little about the patient.

Documenting information about his specific activities, both before and after initiation of treatment, is also the best way of keeping track of, and supporting, any benefit the patient may receive from the treatment plan he has been given.

When a patient reports that in the past he had gone to PT, “but it didn’t help,” don’t just dismiss further PT as an option, but rather consider this statement as the only the start of a conversation. A major goal of PT is to provide a home exercise program, so that there is benefit long after the few PT sessions are over. Did the patient actually do exercises at home or at a gym? Did he follow up on the PT’s suggestions?

When opioids are being considered as a treatment option, risk assessment is an essential component in the prescriber’s decision making. This involves asking questions that you might not generally feel comfortable asking. For example: a health provider, while asking colleagues for suggestions on how to treat a patient who has chronic back pain, reported that this patient was being prescribed 30 mg of immediate-release oxycodone 3 times a day. When asked about the patient’s life, the provider said that the patient is unemployed, is living in a homeless shelter, and has to leave the facility by 8:00 am and can’t return until evening.

It was unclear how the patient spent his day. Where did the patient keep his medications stored? Was there a secure place in the homeless shelter, or did the patient have to carry all his medications around with him? That too was unclear. Another problem is that in addition to the fact that around-the-clock pain is better treated with extended-release analgesics, the immediate-release oxycodone he was being prescribed has a very high street value, and the patient’s precarious financial situation would put him at a high risk of diverting the medication.

The bottom line is, as described by Weiner and Schwartz, that paying attention to the patient’s context is an essential element of good health care.

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